Vernal Keratoconjunctivitis With Giant Papillae on the Inferior Tarsal Conjunctiva

and †Department of Ophthalmology, Kyoto Prefectural University of Medicine, Kyoto, Japan.
Cornea (Impact Factor: 2.04). 11/2013; 33(1). DOI: 10.1097/ICO.0000000000000009
Source: PubMed


In vernal keratoconjunctivitis (VKC), giant papillae are commonly observed on the superior tarsal conjunctiva. We found 3 cases of giant papillae on the inferior tarsal conjunctiva, and diagnosed them as being VKC based on their clinical and histopathological features.
Three patients with inferior tarsal giant papillae were studied. In 2 patients, the giant papillae were resected for therapeutic purposes. Immunohistochemical analysis was carried out by indirect immunofluorescent staining using anti-CD3, anti-CD20, anti-CD35 antibodies.
In all 3 patients, giant papilla formation was observed on the inferior lid margin. Clusters of CD20 B lymphocytes with CD35 follicular dendritic cells, and CD3 marginal zone T lymphocytes, common features of lymphoid neogenesis, were observed. In 2 patients, typical giant papillary formation was also observed on the superior tarsal conjunctiva. In all the patients, topical dexamethasone and tacrolimus treatments were found to be effective.
The giant papillae of VKC can occur not only on the superior tarsal conjunctiva but also on the inferior tarsal conjunctiva. The possibility of the presence of giant papillae on the inferior tarsal conjunctiva should be considered in the clinical examination of patients with VKC.

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    ABSTRACT: Vernal keratoconjunctivitis (VKC) belongs to the group of allergic eye diseases. The incidence varies considerably, depending on the climate zone. In temperate climates VKC occurs only seasonally, while in hot climates it is mostly all year-round and rather more severe. Most commonly boys are affected in the first decade of life. Pathophysiological feature is a dense mixed cellular infiltrate with sometimes extremely thickened epithelium. It shows pronounced capillary proliferation, fibrosis and a thickened extracellular matrix. Inflammatory responses can be divided into IgE-mediated and non-IgE mediated inflammation. The clinical picture is characterised by pronounced subjective symptoms and the emergence of giant papillae, mostly on the upper tarsal conjunctiva. Distinction can be made into a limbal form and a palpebral form. Corneal changes are the most threatening complications with development of corneal erosions and shield ulcers. The therapeutic approach uses mainly drugs to block the release of inflammatory mediators such as histamine. These are usually local antihistamines and dual action preparations. Topical steroids or topical calcineurin inhibitors are only used in more severe situations. The same applies for the use of systemic corticosteroids or new biologics e.g., IgE inhibitors. Surgical therapy is predominantly required for the treatment of corneal complications. In general, VKC usually has a self-limiting course. However, during phases of inflammation with the risk of developing vision-threatening complications therapy is always indicated.
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